5 N 5th Street Mail Center –Harrisburg PA 17101 ...

Commonwealth of Pennsylvania - Public School Employees' Retirement System

5 N 5th Street Harrisburg PA 17101-1905 Toll-free: 1.888.773.7748 psers. Fax: 717.772.3860

Authorization for Direct Deposit ? Electronic Transfer of Monthly

Benefit

PSRS-116 (04/2020)

Instructions: The payee must complete this form. All entries must be typed or legibly printed in black ink.

Payee Name

SSN or PSERS ID

Date of Birth

0116 Mail Center

Which monthly pension account(s) does this affect? (check all appropriate boxes)

My retirement benefit

Benefit I receive as a survivor annuitant/beneficiary

Divorce benefit

Payee Agreement: I hereby authorize and request the Pennsylvania Public School Employees' Retirement System (PSERS) to direct the net amount of my monthly benefit for electronic deposit to the financial institution and account number indicated below. This authorization is not an assignment of my right to receive payment from PSERS. This form supersedes all previous electronic transfer requests and revokes all prior payment arrangements I may have made with PSERS. In the event of my death, the finan cial institution shall refund to PSERS any payments that were credited after the date of death and which were not legally payable, as determined by PSERS.

The authorization will remain in effect until I give written notice of its termination to PSERS in such time and in such mann er as to allow PSERS a reasonable opportunity to act upon it. I agree to notify PSERS if I wish to change the designated financial in stitution or account to which my net pay is to be deposited sixty (60) days prior to the effective date of such change. I understand t he financial organization reserves the right to cancel this agreement by notice to me.

Payee's Signature ? Print this form, sign and date it, and return it to PSERS

Date Signed

Depositor Account Number

Name of Financial Institution Address of Financial Institution City

Telephone Number of Financial Institution (include area code)

State

ZIP Code

+4 (Optional)

Routing Number

Account Type to be Credited (check one)

Checking

Savings

NOTE: Routing number should be the first 9 digits of the number at the bottom left on your check. See example for location of Routing Number and Depositor Account Number.

If you are unsure which numbers to use, please contact your financial institution to clarify the appropriate information.

Authorization for Direct Deposit - Electronic Transfer of Monthly Benefit

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